Checking on Patient Wellness

Checking on Patient Wellness. Image credit: © Jade Maas / peopleimages.com - stock.adobe.com

Do you ever wish you could erase things in life like an Etch A Sketch? Maybe you would erase a poor choice as a teenager, an angry moment as a parent or maybe the whole dang dental hygiene appointment. I sure do. I would love to shake the red gadget and start over. Ditch the expectation to see a patient every hour and put all their care into that hour which may or may not suit them. Based on the rampant disease in our country, we know that half to three quarters of the adults we see will need something other than that typical 1-hour they are scheduled for. Grab your pencil and let’s sketch a plan to turn the average prophy appointment into an oral wellness check-up or rather a check-in.

The first thing we aren’t going to draw is an expectation about what a patient needs before they sit in our chair. It does not matter if they are new to us, new to our practice, or have been coming to us since before Hilda graduated hygiene school in 1974. We will approach each person with curiosity. That begins with their medical history. “Sarah let’s chat about your medical history.Medications and ailments have a direct effect on your oral health and vice versa.” Then allow plenty of time to explore what Sarah is working with from a total body standpoint. We may not be experts in every other system in the body, however, we are highly skilled screeners with enough information to point Sarah in a good direction if something about her health appears off.

Right after a thorough conversation about the patient’s medical history, let’s sketch in a couple of moments where we get to take blood pressure. Yes, we get to. Every time. I consider this part of the appointment such a privilege. This is not the time to be tentative about offending people. This is our chance to mitigate the effects of disease within our patient population. The care that we provide and the knowledge we share can save lives. Imagine having a conversation about hypertension with a 42-year-old Dad that went on the receive care for his silent, yet present cardiovascular disease. That care translated into a major lifestyle change that prevented said dad from an early death at age 48. Thanks to our tactful conversation, a re-found love for exercise, and some vegetables, Dad is attending his daughters’ high school graduations and going to get to walk them down the isle at their weddings. Prior to our chat, Dad had not been to a doctor for a physical since his junior year at age 17 when he was the football quarterback. In general, he felt fine and had no idea his atherosclerosis was sneaking up on him like the angel of death. Don’t you want to be the hygienist that started this cascade of events? I know I do. We never know when our words are going to powerfully impact an entire family and community. Why not do the best we can, in all the ways we can?

Side note- I co-delivered a course last night where we discussed heart disease and blood pressure. Many hygienists talked about the backlash they have received from other providers about “staying in their lane.” A few claimed that they have been discouraged from having total body wellness conversations with our patients. Y’all, we must respectfully disagree with that statement and the sentiment behind it. The periodontium is directly connected with the cardiovascular system. Porphyromonas gingivalis, Aggregatibacter actinomycetemcomitans, and Fusobacterium nucleatum (Pg, Aa, and Fn) are all found in atherosclerosis after having originated in the mouth. We also know that one inflammatory disease increases a person’s risk for another inflammatory disease at a minimum of 5-fold. Americans visit their dentist more than their doctor making the need for us to complete a basic screening incredibly necessary. Furthermore, if a patient has periodontal disease, an elevated blood pressure reading is excellent evidence for the case that our patient needs to address the inflammation in their body. Good thing they are here today because we will help them start with their oral inflammation that will have a direct effect on their overall inflammation. If you receive negative chatter about this topic, I invite you to share the details on cardiovascular disease as it relates to periodontal disease. Couple that with the fact that we lose 800,000 Americans every year to cardiovascular disease (150,00 to stroke, 650,000 to heart disease). Those well-intended yet inaccurate medical professionals will reconsider their stance on what our “lane” is. If we really want to sketch a brilliant care system for our patients, we will seek out those other providers and build relationships. I would love to see it become common practice for dentists, general practitioners, specialists, nurses, and the like become friends that regularly have tea and discuss the needs of our community. Imagine what a difference we could make if all the health care practitioners in the community worked together for prevention of disease, co-treatment of present disease, and well-rounded education for the population we serve……. We may have to ditch the Etch A Sketch, grab an easel, and a brilliant set of paint colors. This picture is getting more vivid and gorgeous by the minute. Alas, we must start somewhere. Together, you and I will sketch out our dental visits then revisit the other entities of health care at a later date.

Sketching in a quality oral cancer screening is our task now. What is normal for Chad? This is when we find out. As we complete the extra and intra oral exam we notice that Chad has a swollen thyroid on one side. Since about 20 million Americans have thyroid disease, we aren’t surprised to find an abnormality for Chad. He had no idea and has since gone to his doctor and found that his thyroid is not functioning properly. He doesn’t have cancer but is taking some supplements to correct the dysfunction of his thyroid. Chad is super grateful that we took the time to provide such exquisite care. His energy levels have returned to normal and because he caught the problem early, he doesn’t have to take medication. Another day saved by an RDH. Yahoo!

Now it is time to draw in the x-ray portion of the appointment. It is critical that we take high quality images that show all the information we need to make an accurate diagnosis. We need a straight on view of the interdental bone, open contacts, and the roots of all the teeth. Depending on the risk factors of each patient the timing will vary. Personally, I want to see in between the back teeth and the bone there every year, the periapical area of the anterior teeth every 2 years, and all the roots every 5 years. If there is any reason for concern, I will happily snap a new film before that time frame. We live in a digital world where the risk of radiation from dental x-rays is so minimal that it is a no brainer to just get the films and/or retakes that we need. One important reason we need these great pictures is for our patient’s ability to diagnose their own disease. If the films are poor, the contacts are closed, and the alveolar bone is missing altogether, how are we (the dental professionals) supposed to diagnose the disease? You are right. We can’t. And neither can Joan. So, let’s take great films!

As we spin the knobs on the Etch A Sketch, we arrive at my favorite part of the appointment. Here is where we draw in adequate time for recording or updating a periodontal chart. We need to allow time for measuring every tooth, every time. Our number one indicator of active disease is bleeding. Simply guessing is a mistake in my opinion. In health, checking all 6 locations of each tooth takes less than 2 minutes. When we need to record depth changes and bleeding points, it takes more time. Usually, the patient needs more care at this point and the extra time at this juncture sets the patient up to understand what their needs are and equip them with tools to address said needs. This is where a hygiene assistant comes in handy. If you don’t have an assistant there are several tools available to aid in efficient charting for your patient. The critical piece to periodontal charting is to say the numbers and bleeding points out loud. When Bob hears, “1-3 mm is normal and healthy gums don’t bleed or hurt while I am measuring.” Then proceeds to hear 4, 5, 6, and 7 with generalized bleeding, you don’t have to tell Bob he has gum disease. He figured that out all on his own, thank you very much.

The above 5 steps of quality oral wellness check ins are non-negotiable in my opinion. The medical history, blood pressure reading, oral cancer screening, adequate x-rays, and full mouth periodontal charting are a fabulous picture of what is happening currently for our patients. In health, that entire routine takes less than 20 minutes. That leaves 25 minutes for instrumentation, polish, and varnish. Leaving the last 15 minutes available for an exam, rescheduling, and a warm hand off to the front desk administrative team. Please invite the doctor in for an exam anytime after your assessment is complete. This system creates a healthier flow for the entire practice. It also insulates your patient from having to wait for an exam should the dentist be busy at the moment you finish rinsing the polish out of their mouth. This works if excellent hygiene care is standard procedure and there is trust and mutual respect. The result makes the dentist’s need to “check our work” non-existent. When the doctor does arrive for the exam, briefly update them on what you and Jose found during the assessment. Set the conversation up for team collaboration. Give the doctor an opportunity to confirm the findings and support the game plan. This type of teamwork takes practice and time spent reading x-rays and periodontal charts together outside of the operatory. I urge us all not to skip this prep work required for team unity. A united presence with the patients is effective while differing opinions instills confusion and trepidation in Jose. We are sketching an efficient and thorough dental hygiene appointment that supports Jose taking action for his oral and overall wellness. If we confuse him, he will not proceed with care here or make modifications at home.

Should you have a picture that has all 5 of those steps already in place and would like to take this oral wellness check in to the next level, I would invite you to add in one item of interest to you. This will challenge and invigorate your RDH soul. Intra-oral pictures are a phenomenal adjunct for patient education as well as documentation. Everything from mouth sores, old fillings, recession, and bruxism can easily be recorded and monitored with precise accuracy over the course of time. I have seen skilled clinicians snap an entire mouth worth of pictures in 2 minutes. The profound information this provides is well worth the 120 seconds it takes to collect the photos.

Another emerging adjunct for amazing assessment is saliva testing. This technology is becoming more user friendly and less cost prohibitive by the year. While the information does not necessarily change the game plan for the patient’s periodontal treatment plan, it can change their motivation to care well for themselves. Learning that the bacteria in their mouth are the same strands found in clogged arteries and spinal fluid of people with Alzheimer’s disease is likely to allow you to forgo the brushing and flossing speech forever. They will not want anything to do with either one of those life destroying diseases. By the way, Costco is having a sale on a 2 pack of power toothbrushes. Our patient, Felix is planning to stop on his way home from his appointment today, purchase, and then use the power toothbrush from here on out (wink, wink)! Saliva testing as an assessment adjunct is also great for those of us that like to geek out on data. For example, yours truly. If something lights your fire for your career, the cost in time, effort, and money is well worth it. Don’t forget if you try something and don’t love it, you do not have to do it forever. Many companies with products like this offer a deal on a trial package. I encourage you to give it a go if it looks fun and/or beneficial to your patients. I have yet to see a professional become more passionate about their days at work and less good at being a hygienist. The two have a positive correlation. Why not capitalize on it?

As we complete the picture of what our assessment sketch should look like, we have brilliantly transformed a basic hygiene appointment into an oral wellness check-in. If at the end of our beautifully drawn assessment our patient needs something other than a prophylaxis, we will have the evidence to support a treatment plan that is reflective of Lanett’s needs. It also allows ample chance for Lanett to learn about her own health. No matter how great of a hygiene appointment we provide, Lanett is the one who will be caring for herself throughout her life. If Lanett were your favorite auntie, would you want her to be equipped to care well for her oral and overall health? I definitely would. For both her oral and overall health an ounce of prevention is worth a pound (maybe ten) of treatment. Let’s make a promise to ourselves and our patients to wipe the slate clean and sketch a hygiene appointment into the most beautiful, comprehensive oral (overall) wellness check in. Happy sketching!